The EHR adoption rate among physicians in the United States is high — greater than 80 percent, according to federal government data — but with federal meaningful use (MU) incentives drying up, what will it take to get the holdouts on board?
Eighty-three percent of U.S. physicians use EHRs, although a slim majority — 51 percent — use only the system’s basic functions, according to a 2015 report by the Office of the National Coordinator for Health IT. The report identifies primary care physicians (PCPs) as the most enthusiastic EHR adopters. Practice size is also a key determinant. In its 2015 Ambulatory EHR User Satisfaction and Loyalty Survey, Black Book Market Research LLC — a healthcare-focused polling, survey and market research opinion-mining company headquartered in Tampa, Florida — found 99.4 percent of practices with at least 50 physicians had adopted EHRs. Roughly the same percentage of practices with 10 to 49 physicians had adopted EHRs, and about 68 percent of practices with two to nine clinicians had done so. Among solo practitioners, the adoption rate was 58 percent.
The Black Book survey also revealed a steep plunge for MU incentives as a motivating factor in adoption. In 2013, these incentives spurred 95 percent of EHR purchases; last year, they drove only 7 percent of EHR acquisitions, mostly for replacement systems.
“MU is focused on adoption and use of EHRs as the final goal, which misses the whole point: that IT in health care ... is a means to achieve the actual goal of efficiency,” says Niam Yaraghi, PhD, Fellow in Governance Studies at the Center for Technology Information at the Brookings Institution, a Washington, D.C., think tank. “More importantly, MU considers EHRs as the only type of IT solution and ignores the fact that there are many other IT services that can help medical providers much more. Current EHRs are not designed to meet the needs of office-based physicians. They are so burdensome and expensive that many physicians will be better off paying the MU penalties rather than adopting these technologies. Given these factors, the low adoption rate of EHRs among individual physicians is not a surprise; rather, it is the expected outcome.”
Meet the Non-adopters
Solo or small-practice clinicians — particularly those who share few patients with other practices — as well as certain specialists and physicians in single-specialty practices have lagged behind PCPs and clinicians in large and/or multispecialty groups in EHR adoption, according to experts and research by the American Academy of Family Physicians. Non-adopters may practice in less traditional settings, one expert says.
“I believe [non-adopters] are subspecialists or providers who work in non-hospital and non-clinic environments, or they do not have their own offices, such as hospitalists who use EHRs but not ambulatory EHRs,” says Joan S. Ash, PhD, MLS, MS, MBA, Professor and Vice Chair of the Department of Medical Informatics and Clinical Epidemiology at the School of Medicine at Oregon Health & Science University. “They may [also] work in nursing homes or mental health areas.”
Ash says cost is likely prohibitive for those who don’t use EHRs, but she is skeptical that a generation gap between older and younger clinicians plays a role.
“I’m sure cost is an issue, but I don’t think age is an issue,” she says. “Many studies have shown that age [isn’t a factor in non-adoption]. In my own research, it hasn’t been an issue. Younger providers get frustrated when the EHR does not have all the bells and whistles, just like older providers get frustrated by clunky technology — the frustrations are equal.”
Impetus for Implementation
Experts agree that a healthcare landscape with patchwork EHR use hampers efficiency and information sharing among providers, as well as the large-scale data analysis necessary for genetics-based personalized medicine. Emerging developments may give the push toward universal EHR adoption fresh life. In January, Centers for Medicare & Medicaid Services (CMS) Acting Administrator Andy Slavitt announced the MU program will likely end this year. Yaraghi believes the end of the program could spur EHR non-adopters to action, and new factors could begin to drive adoption. He thinks one such driver will be vendors’ turning to non-adopters as a kind of final frontier.
“Like any other business, vendors go after easier, more profitable targets first,” Yaraghi says. “That is, large hospital systems that need expensive EHRs. Now that almost all of them have already adopted EHRs, vendors need to find new customers. The only part of the market that still hasn’t adopted is the small practices and office-based physicians.”
Another factor that will drive adoption, Yaraghi says, is the trend of large hospitals and practices acquiring smaller hospitals and physician groups. This already seems to be at work: According to the Black Book survey, 88 percent of new EHR adoptions in 2015 resulted from acquisitions.
Still another reason EHR non-adopters may be more likely to implement digital systems in the future, according to Yaraghi, is a fundamental transformation in what EHRs can do for them. If clinicians are able to use EHRs for analyzing data rather than just archiving information, the systems will bring them greater value, he says.
“An example is [CMS’] Chronic Care Management, which pays physicians to follow up with their patients who have more than one chronic condition,” Yaraghi says. “EHRs allow physicians to easily identify such patients and get reimbursed an additional fee for minor additional effort. This will drive physicians to adopt EHRs to increase their revenue. Data analytics can also help physicians make better decisions easier, which makes them happier and will drive them to adopt EHRs to enjoy such benefits.”
Douglas Brown, Co-founder and President of Black Book, expects many larger, wealthier physician groups to adopt analytics-capable EHRs during the next two years. New or replacement adopters with less money to spend will likely turn to low-cost cloud EHRs.
“The biggest leap in adoption will be from physicians who want smartphone access to patient data,” Brown says. “Not all EHRs are prepared for this. The EHR vendors with mobile applications will grab these adopters.”